The September issue of Health Affairs includes a cluster of studies on the culture of health: how neighborhood characteristics affect health and local efforts can respond to health care challenges. Other topics in the issue include Medicaid, hospitals, disparities, and global health policy.

The culture of health content in the September issue was supported by the Robert Wood Johnson Foundation.

Can Medicaid expansion prevent housing evictions?Medicaid has been shown to reduce poverty, and a new study finds that Medicaid may also improve housing stability. A common challenge facing low-income families is housing eviction, which prior research has shown has serious implications for physical and mental health. To determine whether Medicaid expansion reduced evictions, Heidi Allen of Columbia University’s School of Social Work and coauthors examined information from a privately licensed database of eviction records in fourteen states for the period 2008–13 and compared eviction rates before and after California’s early Medicaid expansion, as part of the Affordable Care Act (ACA). The authors estimate that for every thousand new Medicaid enrollees in California, Medicaid expansion was associated with roughly twenty-two fewer evictions per year. They conclude that these findings show that Medicaid is not only an important part of the health care safety net but may also be a key strategy for addressing poverty-related housing instability.

Physicians, situated on the front lines of health care delivery, serve a vital function in implementing health policy. Despite their crucial role, there have been few analyses of physicians’ views of the ACA, and none examining changes over time. To fill this gap, Lindsay Riordan and Jon Tilburt of the Mayo Clinic and coauthors from other research institutions compared responses to their 2012 and 2017 surveys of US physicians’ perceptions and approval of the ACA. Both surveys were mailed to a random sample of US physicians. In 2017, 53 percent of respondents agreed that the ACA, “if fully implemented, would turn United States health care in the right direction,” compared to 42 percent in 2012—an 11-percentage-point increase. (See the exhibit below.) According to the authors, physicians’ positive attitude toward the ACA increased across all specialty categories. Approval came despite many physicians reporting worsening practice conditions over the past five years, including more time spent on insurance-related issues and less time available to spend with each patient. The Practice Of Medicine series is supported by The Physicians Foundation.

The ACA requires most private health insurance to cover contraception without cost sharing. Long-acting reversible contraceptives (LARCs) are among the most effective—and have the highest upfront costs without health insurance. LARCs include the etonogestrel single-rod contraceptive implant and the intrauterine device (IUD). In the first study to track post-ACA LARC insertions and costs through 2016, Carol Weisman and coauthors from Penn State College of Medicine examined trends in LARC insertions and out-of-pocket spending for LARCs before and after the ACA requirement was implemented, using data from the Truven Health MarketScan claims database for the period 2006-16. The authors found that LARC use continued to increase in each post-ACA year. According to the authors, there was a post-ACA decline in out-of-pocket spending for LARCs, although spending for IUDs increased in 2015–16. The authors conclude that their latter finding raises questions about how employer-based health plans are approaching contraceptive coverage and about compliance with the requirement.

The high cost of fruit and vegetables can be a barrier to healthy eating, particularly among low-income households with children. To test the effects of offering low-income families financial incentives to make healthy food purchases, Alyssa Moran of the Johns Hopkins Bloomberg School of Public Health and coauthors conducted a randomized controlled trial, enrolling some 600 low-income families with children, one-third of whom participated in the Supplemental Nutrition Assistance Program (SNAP), at a supermarket in rural Maine period in in October 2016. About half of the participants received a 50 percent discount at checkout on fruit and vegetables. The authors found that the participants who received the discount showed a 27 percent increase in spending on fruit and vegetables each week, with no increase in purchases of other, less healthful foods. However, due to the limitations of the study, the authors could not detect a change in fruit and vegetable consumption among study participants. The authors conclude that these findings support the benefits of financial incentive programs for the purchase of fruit and vegetables and suggest that effective complementary approaches are also needed to improve diet quality.

People who are homeless have been shown to use more hospital-based care than others, but little research has explored hospital use immediately before and after a shelter stay. In one of the first studies of its kind, Dan Treglia of the University of Pennsylvania’s School of Social Policy & Practice, Kelly Doran of New York University’s School of Medicine, and coauthors linked administrative records from New York City’s municipal shelter system with hospital records to assess the emergency department (ED) and inpatient hospital use of homeless adults before and after stays in shelters. They found that 39.3 percent of first-time adult shelter users had an ED visit or hospitalization in the year before shelter entry, and 43.3 percent had either an ED visit or hospitalization in the year following shelter exit. The authors also detected that ED visits and inpatient hospitalizations were highest on the day of shelter entry (28.1 and 15.4 per 1,000 entrants, respectively) and exit (17.5 and 9.9 per 1,000 exiters, respectively). The authors conclude that hospitals have an opportunity to screen patients for housing instability and connect patients with homelessness prevention and other social services to reduce the chance of homelessness after discharge. Note: Investigators from the New York City Center for Innovation through Data Intelligence (CIDI), a research center in the Office of the Deputy Mayor for Health and Human Services, collaborated in this study.

Also of interest in the September issue:

Moving deliveries to hospitals in low- and middle-income countries

In many low- and middle-income countries, maternal and neonatal mortality remains high. To overcome this problem, in 2005 the World Health Organization (WHO) recommended a “close to client” approach, with delivery for most women in nearby primary care facilities. However, many of the attending providers lack the necessary skills or tools to handle obstetric emergencies. Hospital deliveries could solve this problem, and to determine the feasibility of such a shift, Anna Gage of the Harvard T. H. Chan School of Public Health and coauthors evaluated modeled delivery service redesign in Haiti, Kenya, Malawi, Namibia, Nepal, and Tanzania, using country-specific data compiled by the US-based Demographic and Health Survey Program or from the individual countries. Under the authors’ hospital-only redesign, between 72.9 percent (Tanzania) and 98.3 percent (Haiti) of pregnant women would need to travel two hours or less, an increase in average travel time from seven minutes (Kenya) to forty-six minutes (Tanzania). While the authors acknowledge the challenges of implementing these changes, they note that because primary care facilities are not able to consistently provide lifesaving care, it is time to consider a hospital-only approach